The formal genesis of monsters can often be deduced with a fair degree of satisfaction. For example, it is not difficult to understand the development of a double monster like a thoracopagus, if we assume that in the ovum from which it was developed there were two centers of formation instead of one. On this theory it is quite possible to reconstruct the development of the thoracopagus from its earliest stages to full term. There are many well-established facts which justify the assumption. When, however, one undertakes to reach a conclusion concerning the causal genesis, the etiology of monsters, he approaches a very difficult and obscure question, to which it is not possible now to give a definite answer. The attractive theory of Wilder, that monsters are merely germinal variations from the norm, may or may not be true-it is not possible either to affirm or to deny it. And so, also, as to Mall's generalization, it is very difficult to see the connection between the existence of an endometritis and the formation of many monsters. In recent years, however, some important results have been obtained by experimental embryology which throw light upon the causation of monsters. Thus Stockard has produced large numbers of cyclopean fish monsters by simply allowing the eggs to develop in water containing a certain proportion of magnesium chloride; and W. H. Lewis has been able to accomplish the same thing by puncturing a definite area of the germ with a needle. A certain amount of caution, however, must be observed in transferring these results to human teratology, because (1) these experiments have all been done on the eggs of animals much lower in the scale than man; (2) it is far easier to alter the environment of the germ than to alter its inherited forces, and any monster produced in this way is necessarily pathological in causation; and (3) they show only that monsters can be produced in lower animals by pathological agents, and not that they cannot be produced in other ways. Still, we are perfectly justified in the conclusion that since monsters undoubtedly can be produced by the action of pathological agencies, it is unnecessary to assume a germinal, or inherited, causation. Finally: It has been estimated that for every one hundred thousand pregnancies there are six monsters. On this basis if one could come into possession of all the monsters that are born in Virginia in the course of a few years, he would have a very valuable material. And if he could add to this those which are stored away in doctors' closets and drug stores, he would have enough to keep him occupied for a lifetime. I should be grateful to any member of the Society who can put me into possession of such material. DISCUSSION. DR. W. C. POWELL, Petersburg :--I was very much interested in Dr. Whitehead's paper. Within the last two years have had a case in my practice in which a double baby was delivered. This is the case I reported in the Virginia Medical Semi-Monthly, and also in the Old Dominion Journal. This twin baby was full term-nine months; well developed and still born. These babies were girl babies and were joined together in the thoracic and abdominal cavities. They had two distinct, well developed heads, and two sets of arms, and two sets of legs, and one body. As I said, the case was reported in the journals about two years ago. DR. W. A. PLECKER, Hampton:-It seems to me that the interesting part in connection with monsters is the cause. I do not think Dr. Whitehead has made that perfectly clear. Several years ago I reported three cases of anacephalic monsters in my practice, i. e., with the head gone from the eyes back, and in each one of these cases there was the history of a blow received by the mother about the middle of pregnancy. Two of these fell, striking on the abdomen, and the other struck against the corner of a table; and I thought possibly they may have struck the cranium and produced atrophy. Whether this is true, I do not know; it is only theory. I have been teaching some trained nurses for the last seventeen or eighteen years obstetric nursing, and whenever we come to this subject, I always turn the class loose and ask them to give me illustrations of maternal impressions, and it is an interesting thing to hear the various cases they all relate. I tell them I do not know anything about it, except that we read in the Book of Genesis, where Jacob laid striped rods before the cattle, and in that way got a larger number of spotted cattle, and cheated his father-in-law, Laban. As to whether those rods had any effect on those cattle, I don't know; but it is in the Bible, and I believe all that is in the Bible. DR. R. H. WHITEHEAD, University:-One point I might have mentioned in this connection of practical interest to all of us is the difficulty these cases present in being delivered. The picture I passed around, for instance, was born without any injury to the mother, and it must be very baffling and puzzlings to the physician to find three or four arms and legs at the same time. He might think he was called upon to deliver a spider. As a general rule, they are not delivered without an operation either on the mother or the monster. The question of injuries on the production of monsters is one which I think can be decided favorably in some cases. I think it would be quite possible for an injury to the mother to destroy the proper implantation of the ovum in the decidua, and then the blood supply being imperfect, and may be cut off, might produce just such a monster as the anacephalus. CANCER OF THE STOMACH. By JOHN EGERTON CANNADAY, M. D., Charleston, W. Va. Cancer of the stomach, by reason of the often intolerable lateness of its diagnosis, destroys many lives that might otherwise be saved. Moynihan says that fifteen hundred die from this malady in England each year. The proportion in this country is, I do not doubt, larger. It is only by earnest co-laboring on the part of the physician and surgeon that we can hope for some amelioration of this unfortunate state of affairs. The physician, in making a diagnosis, has usually waited for the last stages of the disease in order to confirm his diagnosis. The first essential in the making of an early diagnosis is the taking of the case history. One must, if possible, induce the patients to dwell on their earliest lapses from a normal state of health. We must pay particular attention to what Moynihan terms inaugural symptoms; they are the only ones the observation of which is of any value in the disease. End symptoms and dead pathology are of scientific interest to the doctor, but the pathology of the living, of the very much alive, is of vital interest to the patient. In most text-books only the late clinical manifestation of stomach cancer are the ones selected for honorable mention, those prominently placed on the records. Late symptoms are no more characteristic of any disorder than the early ones. Why wait for them? The late symptom is frequently the herald of death; the early symptom, the cry in time for surgical assistance. It is always well to get a most detailed statement of the disease life of the patient from its inception, omitting nothing, no matter how trivial. In more than sixty per cent. of cases of gastric cancer there must have been an antecedent condition of ulcer. The two most common types, the pyloric and the prepyloric, give initial symptoms that differ decidedly. In the former the symptoms are obstructive from the beginning and vomiting is seen from the first hypertrophy and dilatation follow early. When the growth has the prepyloric location, the first signs are separately vague, but, taken together, are quite sufficient for a diagnosis to be made. To quote from a recent address of Moynihan, "A man beyond middle life finds by degrees that he takes less interest in his meals, his food loses its relish and presently becomes distasteful. Life, in many of its aspects, seems to lose its zest; neither work nor leisure are enjoyed, and depression, increasing anæmia, and loss of weight are soon observed. It is not for many weeks, perhaps months, that vomiting is noticed. It is then due to the gradual enlargement of a growth, which, beginning on the lesser curvature of the stomach, spreads downward on one or both surfaces, until it attains such size that the pyloric antrum becomes narrowed and obstruction results. In a number of cases hemorrhage is the first symptom. The sudden vomiting of a considerable quantity of blood in a patient supposedly in previous health especially points to cancer. If the patient has an early history leading to gastric ulcer and there comes later uneasiness after meals, loss of weight, anæmia, distaste for food, intolerance and later refusal of solid food, vomiting or hematemesis, the diagnosis of cancer is quite sufficient to warrant operation at once." The symptoms are practically always similar in nature to those described; food, especially meats, either fat or lean, becomes distasteful. There is a sense of uneasiness, distress or "stagnation" in the stomach region, as it is sometimes called by the patient. The patient may tell you that the food remains in the stomach and does not pass on as it should. Soon an easily palpable tumor appears in the epigastrium, the anæmia increases and at times there may be apparent temporary improvement. Dr. J. E. Coleman, of Fayetteville, W. Va., recently asked me to see a rather peculiar case. This patient at one time, even after a tumor could be felt, under careful dieting, gained ten pounds in weight. On abdominal section the growth was found to be so far advanced as to be inoperable. There had been no noticeable bleeding, but, on Dr. Coleman's attempt to use the stomach tube, there was serious bleeding. In four cases of my own, the first thing that caused the patient to seek medical aid was serious gastric hemorrhage. In most cases, the trouble begins rather vaguely, and the patient thinks he has indigestion, etc. An examination of the stomach contents often shows blood, yeast, pus, and bacteria. Since the trouble often follows gastric ulcer, there is usually a gradual transition in symptoms as this change comes about. These patients have for a long time had attacks of indigestion. These are characterized generally by pain, appearing always at a definite interval after food. This is a longer or shorter period, dependent on the character of the food taken. When liquids are taken, the pain comes quickly and leaves in the same way. When heavy solid meals are taken, the pain comes more slowly, but is equally slow in leaving, and a tender spot can be usually made out about the epigastrium, where the pain is localized. The pain may radiate to one side or the other or through to the back. Vomiting comes with neither regularity nor frequency, but gives great relief, and the patient may acquire the habit of inducing it. Attacks are more frequent in the winter season, and worry is a frequent pre-disposing cause. The patient is usually known as a dyspeptic living on a restricted diet. These unfortunates learn that certain articles of food bring on these attacks. They limit the amount of what they eat, and sometimes do not have the pleasure of one full, unrestricted meal for years. When cancer is implanted in the ulcer or its scar, there is a slow, progressive transition that becomes more and more severe. There is great stomachic distress at times, relieved by belching. The food may be restricted to liquids and there is a marked loss in weight. The facial expression is that of anæmia and worry. After the cancerous growth has become established, the distress after eating may be continuous. The patient who has ulcer rarely has a distaste for food, but after cancer is well begun, there is a positive repugnance; food is abhorrent. There is little or no freedom from pain. This pain is not severe, and the patient may not complain of it. Domestic remedies, such as mustard, may be applied for its relief. There is uneasiness or a feeling of sinking in the "pit" of the stomach. The food lies heavily, regurgitation, with a nauseous bitter taste, may be a frequent symptom. In most cases there is flatulence and eructation of gas. At times the gas and vomited matter is exceedingly offensive. The features are sharp and withered, and there is a dry and shrunken appearance of the skin, which is dry and harsh. The appearance of anæmia is more marked in the face than elsewhere. There is a tinge suggestive of jaundice. Pernicious anæmia is suggested, and there is indifference to many things of life which formerly held much for the patient. Progressive loss of bodily strength is noticeable. There may be increasing drowsiness and desire for sedentary life. In the pyloric form, vomiting comes early and dilatation of the stomach soon occurs; then food stasis and periodic return of the food occurs. Vomiting is the symptom of prime importance. The presence of a growth anywhere on the stomach wall seems to seriously interfere with the moving power of the stomach. The examination of a test meal, preceded by fasting and an examination of the contents after a meal composed of albumens principally, should show in characteristic cases, absence of free HCL, a diminished total acidity, the presence of lactic acid and the Boas-Oppler bacilli; gastric analyses give little or no help in early cases, but are often positively indicative later. In another class of cases, especially in people of middle age, no history of any previous illness pointing to gastric ulcer can be elicited. A distinct constantly sustained illness, the persistence of which suggests serious organic disease, may be the very first warning. This persistence attracts attention and suggests serious organic disease. Pain after taking solid food soon becomes so severe that the patient is reduced to living on liquids. There is loss of weight, sometimes vomiting or blood in the stools. In many cases of this sort, gastric ulcer has never been suspected. The ulcer stage may have been of short duration and in that way passed unnoticed. In Moynihan's last one hundred cases of cancer of the stomach, he found that out of every three, two had a previous history of gastric ulcer. Ulcer certainly is a markedly predisposing cause and precedes nearly all cases of stomach cancer. To quote a surgical truism, the onset and persistence of dyspepsia in a man over forty years of age, who had enjoyed good health, is a suspicious circumstance, one very suspicious of carcinoma. As regards the relation between ulcer and carcinoma, it is only the old surgical principle that scar tissue and local irritation are essential predisposing causes. Evidence of the transition from simple ulcer to malignancy can seldom or never be found post-mortem. A friend of the writer once said that when one did an autopsy, he conveyed a message of wisdom from the dead to the living. Quite true in most cases, but not here. Our knowledge in these cases comes from the operating room; not from the cadaver room. Specimens showing the transition stage are not found post-mortem. They must be obtained from the operating room. Dr. W. J. Mayo was able to demonstrate the fact that cancer had sprung from the base of an ulcer in fifty-four per cent. of his cases of resection of the stomach. Most cases of malignancy are situated on the anterior stomach wall, either on or near the pylorus. Since the only rational treatment now known is operative, Rodman's excision of the ulcer bearing area will always be of much value as a means of prophylaxis. While exploratory section is, as a rule, to be deprecated, it is occasionally the court of last resort in these cases. If the numerous patients who are suffering and likely to suffer from this terrible disease, are to have any greater prospect of relief or cure than they now have, the number of exploratory operations will certainly have to be increased. Since there is never proof positive of cancer in an early stage, exploration is a godsend. I fully and unreservedly believe that operation should be advised in all cases of chronic gastric ulcer of more than recent standing. The diagnosis of gastric ulcer is easy and accurate. The later in life, the more urgent the need for operation. Whenever there is gastric stasis, a mechanical blocking can only be relieved by mechanical means. Medical treatment is powerless to cure either of the above conditions. If these precepts are followed, our carcinoma cases will not so often reach the inoperable stage. As a general rule, the operative mortality after gastrectomy for cancer will be from fifteen to twenty per cent., though this will vary much according to the skill of the individual operator and the class of cases selected for operation. FRACTURES INVOLVING THE ELBOW JOINT. By A R. SHANDS, M. D., Washington, D. C. Professor of Orthopedic Surgery, George Washington University, and The University of Vermont. My experience in the treatment of fractures of the lower end of the humerus involving the elbow joint, has been such as to justify me in saying that it is an accident almost peculiar to childhood; although I am not borne out in this statement by the text-books on fractures, for I have, in looking over the authorities, observed but one who speaks of it in connection with childhood. Dr. Duncan Eve, of Nashville, Tenn., is the only one that I have found that speaks of it in this connection. In his treatise on fractures in the "American Practice of Surgery," he says, "Fractures of the lower end of the humerus are especially frequent in children, in whom they are caused either directly by a fall or a blow on the elbow, or indirectly by a fall on the hand." My experience in treating fractures in children has been that fractures involving the elbow joint have been far more frequent than any other fracture. It is very surprising how easily a fracture of the lower end of the humerus is produced in a child by a very slight force when it is received in the right direction. Case No. XIII herein reported illustrates this point (see photo V.) very forcibly, for it was one of the worst comminuted fractures of this variety I have ever had to treat, and was caused by the child falling from a little tricycle-a distance of not more than eighteen inches. This was a much worse case than No. XVII, which was caused by a child falling from a tree-a distance of eight or ten feet. (See Photo VII.) It is not my purpose to give you an essay on the subject of fractures, but to again urge the operative treatment of fractures involving the elbow joint, especially in children, trusting that the report of my cases will emphasize the importance of this method of treatment. I read a paper on this subject before the Medical Society of Virginia in 1900, reporting cases treated by the operative method, with perfect results. It is my purpose now to add to that report a report of the cases treated by me by the same method since that time. That I became convinced in 1896 that one was not justified in adhering to the older methods of treating fractures by manipulations and splints alone. method did not appeal to me, and I at that time began to operate on all cases in which the X-ray showed that the fragments were not properly reduced by manipulations. The older writers on this subject always advise that a fractured elbow should be put up in a right-angled splint, expecting the result to be an ankylosed joint; any other result was a surprise, and when a movable joint was obtained in one of these cases, it was usually accompanied with a very marked deformity. Some advised using no splint at all, so that passive motion would be constant, hoping that a movable joint would be obtained, regardless of the amount of deformity. Dr. Agnew says that complete reduction is rarely obtained, and that ankylosis of the joint may be looked for, not only from the involvment of the joint, but from the inflammatory deposit about the origin of the pronator and flexor muscles of the forearm. He also advised the use of right-angled splints that the arm may be of greater use in case of an ankylosed joint. I have recently reviewed many of the standard surgical text-books of the very latest issue, and have found only one reference to the operative treatment of fractured elbows. This was by Wilms in von Bergman's Surgery. He gives a most exhaustive treatise on the subject of fractured elbows, and gives in detail an account of the many classifications of the different fractures involving the elbow joint. In his closing paragraph, he says that the question of operative interference usually arises after recovery in the cases in which expectant treatment-meaning failure to reduce displacement of the fragmentshas produced marked functional disturbance. It is very evident that the operative treatment of these fractures is not practiced extensively, if at all, in Germany, for Wilms says in the same paragraph above quoted from that at the present time there is no doubt that the |